Success with Treatment Resistant Clients

1. Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP

2. Objectives • Peruse data on the importance of the subject • Explore most common types of treatment resistant clients • Examine why some clients become treatment resistant • Importance of the therapeutic alliance • Eight strategies to improve care of difficult patients

3. What do we do when a client is treatment resistant?

4. “Step On Them Until They Get It”

5. “For Online Counseling, Simply Yell at the Computer”

6. Definition Bad Definition-TRD has been defined in conceptually restrictive terms as symptomatic non-response to physical therapies alone, with little systematic study of etiology made. Good Definition-TRD should be re-defined as the failure to reach symptomatic and functional remission after adequate treatment with physical and psychological therapies.

7. Proposed Criteria for Treatment Resistance TRD is the failure to achieve sustained remission (Remission) defined as absent or minimal depressive symptoms and absent or minimal functional impairment, for at least 8 weeks. There has been adequate treatment of comorbid physical and psychological disorders. Wijeratne & Sachdev, 2008

8. EAP “Real Life Considerations” • Economic variables suggest that clients want to exhaust “all of their sessions” • EAP clinicians feeling more obligated to accommodate client needs • The value added for providing excellent care instead of simply referring has a domino effect (happy accounts and families)

9. Counselor Negative Feelings • Feeling sorry for patient • Feeling powerless • Worrying about patient • Feeling a failure • Feeling deskilled • Feeling drained by patient • Finding patients painful • Frustration with work

10. Counselor Positive Feelings • Enjoying the challenge • Satisfaction with work • Embracing needed changes in clinical practice • Difficult clients expand our expertise • Sharpen our intuition about tx options • Give us a history to rely upon for future encounters

11. The “Best Practices Caveat” • Remember, do what’s best for the client’s care • Sometimes referring is the best option • Don’t allow the client to talk you into doing work that is unbeneficial or unethical • Always consider the reality of mental health disorders

12. Why is this subject important?

13. The Numbers • Mental Health Conditions ranked as one of the top five most costly conditions • Mental Health Conditions had the largest increase in expenditures from 1996-2006 • The number of people with expenditures associated with the top five conditions increased the most with Mental Health Conditions 19.3 million to 36.2 million

14. Expenditures for the Five Most Costly Conditions (billions)

15. Number of People with Expenses for the Top Five Most Costly Conditions (millions)

16. Why are clients resistant? Socio-demographic variables Economic status Quality of life Genetic variables Family predispositions Cultural variables Does treatment adequately account for cultural significance (spirituality, family, natural supports)

17. How Do We Know When a Patient is Resistant? Current Psychiatry • denial of illness • poor stress-coping and relationship skills • social and professional isolation • inability to accept feedback

18. How Do We Know When a Patient is Resisitant • complacency and overconfidence • failure to attend support group meetings • dysfunctional family dynamics • feelings of self-pity, blame, and guilt.5

19. Most Common Resistant Types • ‘Dependent’- Demand continuous attention yet are unaware of their neediness • ‘Entitled’- May use intimidation, guilt, threats to get counselor to conform • ‘Help Rejecting’- Demand care but don’t show faith in tx. Don’t follow tx plans • ‘Self-destructive’- appear unaware of their dangerous actions

20. Substance Abuse and Comorbidity

21. Psychiatric Comorbidity • Posttraumatic stress disorder • Other anxiety disorders (such as panic disorder without agoraphobia, simple phobia, or social phobia) • Major depressive disorder • Cognitive impairment (organic disorders)

22. Medical Comorbidity • Medical • Hypertension • Fatty liver disease • Gastrointestinal hemorrhage • Brain atrophy • Reproductive system irregularities

23. What About The Brain?

24. Getting The Brain “On Track” • Goal Setting • Mental Rehearsal • Self Talk • Arousal Control • Sounds like short-term EAP work to me!!

25. What Are the helpful therapeutic variables?

26. The Doctor-Patient Relationship

27. Psychological Model vs. Pharmaceutical Model • Psychological Model -explains results of treatment in terms of the personality of the doctor, the personality of the patient, and the relationship that they develop • Pharmacological Model -explains results • of treatment in terms of biological changes in the brain caused by the specific pharmacological agent

28. Doctor Patient Relationship • A study showed that the outcome of treatment with antidepressants for patients of doctors who were experienced as lacking in communicative skills deteriorated—at least when it came to disability and activity limitation—while patients of doctors experienced as good communicators improved (Van Os et al., 2005).

29. Doctor Patient Relationship • Those results can be seen as evidence for the psychological model, in that prescription of antidepressants are only effective in the context of a relationship with a doctor who is experienced as empathic and understanding.

30. Why Counseling? • The large-scale Sequenced Treatment Alternatives to Relieve Depression (STAR*D) and other studies have suggested that a structured psychotherapy such as cognitive behavior therapy may be as effective as medication in initial drug non-responders.

31. How Long Do We Treat the Difficult Client 12 weeks average before determining patient was severely treatment resistant CBT counselors more likely to refer than Psychodynamic counselors CBT clinicians more likely than Psychodynamic clinicians to use treatment approaches based on efficacious research results

32. EIGHT STRATEGIES TO IMPROVE CARE OF TX RESISTANT CLIENTSJohn Battaglia, MD

33. Acknowledge That the Client is Difficult • Acknowledgement breeds relaxation • Denying frustrations can lead to mistakes • Clients can sense our “flux” • Depending on your theoretical orientation, “bring it in the room”; i.e., “I’m finding it difficult to find just the proper resource, I’m wondering if you can shed some light?”

34. Develop Empathy • Empathy- Identifying with and understanding why a person feels, thinks, and acts as he or she does • Learn from the client not the textbook • Interview as if you want to write a brief bio of the patient • Think relationship not pathology or symptoms

35. Seek Out Supervision or Consultation • Gain a new prospective from colleagues • Increase your energy and creativity • Decompress by “getting it off your chest” • Stay out of trouble by not having your judgment clouded • Remember ethics; peer supervision is a major component of the profession

36. Utilize a Team Approach • Difficult clients are exhausting • Having a team can lessen the liability • Can decrease the client’s intensity of targeting one counselor to have the answer • Helpful in developing a multi-disciplinary approach

37. Lower Treatment Goals • Aim for stabilization before improvement • Behavior modification is gradual • Success breeds success • Allow the client to conceptualize the change • Client may be in precontemplation stage • Sometimes we’re treating the wrong symptoms; consider changing the goal

38. Decompress the Treatment Timeline • Person-centered counseling- am I reflecting my client in therapy • Don’t make time the marker, instead allow improvement to be milestones • Manage care is not as hard to navigate as we think; negotiate the terms of therapy with case managers when possible • Visualize treatment plan as being maintenance- driven as appose to cure-driven

39. Use “Plussing” • Plussing- using positive comments and acknowledgments, small compliments • Difficult clients can be dreadful, don’t let them change the temperature of the room • When patients are liked, they are willing to try new interventions

40. Use Imagery • Visualize client as the central character in an unfinished novel of their life • You as the clinician are in the book as well • Enjoy the rich, complex nature of each character, without personalizing the results.

41. Expanding the Literature • More data needed on reaching and retaining remission in counseling • How do counselors better account for client’s natural supports? • What is the value of cultural nuances in treating difficult clients? • Capture more data on interpersonal therapies that are at least qualitatively successful (counselor’s intuition)

42. Resources • www.star-d.org • www.currentpsychiatry.com • PsychiatricAnnalsOnline.com

43. Sources • ANKARBERG, P. & FALKENSTRO¨M, F. 2008. Treatment of depression with antidepressants is primarily a psychological treatment. Psychotherapy Theory, Research, Practice, Training, 45(3), 329-339. • Battaglia, J. 2009. An empathic, relaxed approach can ease frustration and improve the therapeutic alliance. Current Psychiatry, 8(9), 25-29. • MCPHERSON, S., WALKER2, C., & CARLYLE, J. 2006. Primary care counsellors’ experiences of working with treatment resistant depression: A qualitative pilot study. Counselling and Psychotherapy Research, 6(4): 250-257 • Muskin, P.R. & Epstein, L.A. 2009. Clinical guide to countertransference: Help medical colleagues deal with difficult patients. Current Psychiatry, (4), 25-32. • Rush, J.A., Kilner, J., Fava, M., Wisniewski, S.R., et al. 2008. Clinically relevant findings from STAR-D. Psychiatric Annals, 38(3).

44. Sources, Continued • Soni, Anita. The Five Most Costly Conditions, 1996 and 2006: Estimates for the U.S. Civilian Noninstitutionalized Population. Statistical Brief #248. July 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st248/stat248.pdf • Stewart, R. E. & Chambless, D.L. 2008. Treatment Failures in Private Practice: How Do Psychologists Proceed? Professional Psychology: Research and Practice, 39(2), 176–181. • Wijeratne, C. & Sachdev, P. 2008. Treatment resistant depression: critique of current approaches. Australian and New Zealand Journal of Psychiatry, 42, 751-762.